PT - JOURNAL ARTICLE AU - Asiedu, Amos AU - Haws, Rachel A. AU - Gyasi, Akosua AU - Boateng, Paul AU - Malm, Keziah AU - Ntumy, Raphael AU - Oseni, Lolade AU - Tetteh, Gladys TI - Improving Malaria Case Management and Referral Relationships at the Primary Care Level in Ghana: Evaluation of a Quality Assurance Internship AID - 10.9745/GHSP-D-23-00050 DP - 2023 Dec 22 TA - Global Health: Science and Practice PG - e2300050 VI - 11 IP - 6 4099 - http://www.ghspjournal.org/content/11/6/e2300050.short 4100 - http://www.ghspjournal.org/content/11/6/e2300050.full SO - GLOB HEALTH SCI PRACT2023 Dec 22; 11 AB - Key FindingsCommunity health officers (CHOs) who participated in the internship program increased their knowledge and skills in malaria case management and diagnosis and treatment of febrile illnesses.Three months after the internship, interns retained clinical competency gains in history taking, severe malaria assessment and referral, and fever assessment, but competency in managing acute respiratory infections declined slightly.A novel feature of the CHO internship was facilitating supportive relationships between CHOs and mentors based at each CHO's assigned district referral hospital, which promoted strong relationships that are essential to timely referral and effective management of severe malaria.Key ImplicationsIf these promising findings are confirmed by an impact study, malaria program managers might consider expanding training for community health nurses so they are equipped with the requisite clinical skills to diagnose and manage febrile illnesses, including malaria, as well as to make timely and appropriate referrals for severe malaria.Policymakers could increase the involvement of non-physician cadres in providing malaria case management services by offering appropriate clinical training and support.Policies to ensure that strong, supportive relationships are in place between referral facilities and primary health centers can support effective referrals.In Ghana, Community-based Health Planning and Services (CHPS) compounds managed by trained nurses and midwives called community health officers (CHOs) play a major role in malaria service delivery. With heavy administrative burdens and minimal training in providing patient care, particularly for febrile illnesses, including malaria, CHOs struggle to comply with the World Health Organization's test, treat, and track initiative guidelines and appropriate referral practices. A clinical training and mentorship program was implemented for CHOs to prevent and manage uncomplicated malaria and offer appropriate pre-referral treatment and referrals to district hospitals. Medical officers, pharmacists, midwives, health information officers, and medical laboratory scientists at 52 district referral hospitals were trained as mentors; CHOs from 520 poorly performing CHPS compounds underwent a 5-day internship at their assigned district referral hospital to improve knowledge and clinical skills for malaria case management. Three months later, mentors conducted post-training mentoring visits to assess knowledge and skill retention and provide ongoing on-the-job guidance. Significant percentage-point increases were observed immediately post-internship for history taking (+12.0, 95% confidence interval [CI]=8.3, 15.1; P<.001); fever assessment (+24.9, 95% CI=20.9, 29.3; P<.001); severe malaria assessment and referral (+32.0, 95% CI=28.2, 35.8; P<.001); and knowledge assessment (+15.8, 95% CI=10.0, 21.3; P<.001). Three months later, a third assessment revealed these gains were largely maintained. Analysis of national health management information system data showed statistically significant improvements in testing, treatment, and referral indicators at intervention CHPS compounds after the intervention that were not observed in comparison CHPS compounds. This training and mentorship approach offers a replicable model to build primary care provider competencies in malaria prevention and management and demonstrates how developing relationships between primary care and first-level referral facilities benefits both providers and clients. More methodologically rigorous studies are needed to measure the impact of this approach.